Student Emergency Form

I authorize my child's music teacher to grant consent for medical treatment in an emergency for my child in my absence on November 11 & 12, 2017 by submission of this form through mail and electronic submission. I assume all financial responsibility for medical cost over and above my insurance benefits.
Music Teacher Name*
First Last
School Name*
Student's Name*
First Last
Parent/Guardian's Name*
First Last
Relationship to Student*
Cell Phone #*
Aternate Phone #*
Emergency Contact Name*
First Last
Phone #*
Cell Phone #*
Insurance Company*
Policy Holder*
Policy Number*
Group Number*
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